Continuing Sedation a Fig Leaf for Euthanasia, Study Finds

Palliative sedation, which has often been held up as a more legally and
morally sound alternative to euthanasia, may in fact have become a different
form of euthanasia, Belgian researchers say.

Rather than putting chronically ill patient under heavy drugs to help make
their deaths as painless as possible, continuous sedation “is frequently used
to hasten the patient’s death,” Vrije Univesiteit Brussel researcher Sam Rys
says in a surprising new study.

“In some cases,” Rys and four colleagues found, palliative, continuing sedation
until death (CSD) “can even be considered a substitute for legal euthanasia.”

Matter Of Motive

Doctor-assisted suicide has been illegal in the United States for ages,
but the modern legal standard was set by two cases in 1997, when the Supreme
Court ruled, in part, that people don’t have “a right to die” and that the
option of continuing sedation (or “terminal sedation,” as the justices termed
it) was more acceptable than outright euthanasia because putting a patient into
a drug-induced coma and then withholding care didn’t require actual intent to
kill, as prohibited by law.

“Just as a state may prohibit assisting
suicide while permitting patients to refuse unwanted lifesaving treatment,” then-Chief
Justice William Rehnquist wrote for the majority in Vacco v. Quill, “it may permit palliative care related to that
refusal, which may have the foreseen but unintended ‘double effect’ of
hastening the patient's death.”

In much of Europe, however, both euthanasia and terminal
sedation are legal, and Rys’ findings, published in the August issue of the Journal of the American Medical Directors
Association (JAMDA), suggest that palliative sedation is increasingly just
a fig leaf for doctor-assisted suicide. In the Belgian region of Flanders,
sedation and euthanasia rates have doubled over the past decade.

In Flemish nursing homes, though, sedation has tripled; it
factored in less than 3 percent of all deaths in 2001, but in 9.4 percent of
deaths in 2007, even while “euthanasia remains a rare practice in nursing homes
compared with other care settings,” Rys writes.

‘Explicit Intention’
To Hasten Death

R

ys and the team surveyed nearly 400 doctors in Flemish
nursing homes, asking about their approach to sedation. Of the 156 physicians
who (anonymously) reported their motives for sedating critically ill patients,
more than three-fifths denied wanting to hasten their patients’ deaths. But
nearly one-third reported “a partial” hope and another 5 percent said their
“explicit intention” was to hasten death.

More than 37 percent of those doctors who were partially or
explicitly hoping to speed up their client’s death had talked with their
patients about euthanasia before sedating them. About 22 percent of those
sedations came because the patients had expressly asked to be euthanized, Rys
says. Of those who were asked by their patients for assisted suicide but who
opted for aggressive sedation rather than outright fatal doses, nearly 40 said
that they didn’t want to go through the legal hassles of state-sanctioned euthanasia.

“Bearing in mind the restrictive policies on euthanasia in
nursing homes in Flanders,” Rys says, “and the significantly low rate of legal
euthanasia in this care setting, our findings strongly suggest that CSD is
sometimes being used as a substitute for euthanasia.”

But those patients who were sedated in the partial or
explicit hopes of accelerating their death were also more likely to have been
involved in their own care planning. Nearly two-thirds of those patients who
were sedated in the hopes of speeding up death were “actively involved in
decision making,” the Belgian researchers say. For those patients who were
already incompetent, the doctors consulted with their families in more than
two-thirds of the cases where sedatives were administered in the hope of
hastening the patient’s death.

Important Questions

In a separate editorial in the same issue of JAMDA, Dutch palliative care expert
Daisy Janssen says the Flemish study “raises several important questions” and
that doctors everywhere should think about palliative sedation carefully.

First, Janssen says, there are conflicting studies about
whether the sedation actually speeds up death. Rys’ team found that the average
patient in their study died within about two weeks of being given aggressive
sedation, but other studies have come back with different net time periods.

Then there is the question of motive. Many physicians say
they only wish to relieve suffering, Janssen says. But some evidence suggests that
sedation only makes it worse. “A case series of continuous deep sedation until
death in nursing home patients with dementia,” for instance, “has shown that
patients may suffer from symptoms such as fear, pain, restlessness, and
breathlessness, despite the use of deep sedation. For three of 11 sedated
residents, nurses experienced the dying process as a struggle,” Janssen says.

Docs Conflicted Over ‘Good
Death’

Other studies have clouded the notion of motives in different
ways—a 2002 “vignette study” among Japanese oncologists and palliative medicine
physicians, for example, “revealed that physicians who demonstrated higher
levels of emotional exhaustion were more likely to choose continuous deep
sedation for patients with refractory physical and psychological symptoms,”
Janssen says. “Moreover, physicians with more experience in end-of-life care
were less likely to choose continuous deep sedation for patients with
depression or delirium, but considered other treatment options.”

Janssen wonders, also, if some doctors aren’t simply in over
their heads. She cites a 2012 study in her native Holland that found that only
22 percent of doctors were asking the advice of palliative care experts before
sedating their patients.

“The study from Rys et
al. in this issue of the Journal
shows the complexity of the process of decision making concerning continuous
deep sedation,” Janssen concludes. “Both the feeling of physicians that they
have the duty to provide a good death and pressure from family members or other
health care professionals pose a challenge on physicians caring for dying
patients.”